DIAGNOSIS AND MANAGEMENT OF COVID-19 INFECTION
IN CHILDREN

Sri Lanka College of Paediatricians, Family Health Bureau and

World Health Organisation (WHO)- Sri Lanka

6. Management Of A Child With Confirmed Covid-19 Infection

It is emphasized that all children, despite their symptoms or COVID-19 contact status, should receive the maximum appropriate care in all instances and at any level.   Appropriate PPE (as specified by the Ministry of Health or local institution) should be used in all situations when attending a suspected child. However, if a high level of protection is necessary for certain instances such as resuscitation of a child or engaging in an aerosol-generating procedure, full PPE should be worn.   Please refer to the algorithm for caring for children suspected or confirmed with COVID-19 infection.   A caregiver should accompany the child irrespective of his/her COVID-19 status.   6.1 Management of asymptomatic children Asymptomatic children are managed in the designated area for children with COVID-19 in the admitting institution or in an intermediate care center. The child should be monitored for the development of symptoms/signs and complications.
  • Monitor the vital parameters (heart rate, respiratory rate, oxygen saturation) three times a day or more, depending on the risks identified.
  • Warning signs for immediate medical attention: Development of difficulty in breathing or saturation at rest in room air is <96% or <94% after mild exertion
  • Continue medication for underlying comorbidities
Please note: Home management guidelines for asymptomatic children or mild diseases will be published if home management is implemented officially.   6.2 Management of mild disease   Children with mild disease are managed in the designated area for children with COVID-19 in the admitting institution. Symptomatic management and supportive care are recommended
  • Monitor the vital parameters (heart rate, respiratory rate, oxygen saturation) three times a day or more, depending on the risks identified.
  • Paracetamol 10-15mg/kg/dose for fever. Avoid NSAIDs unless indicated due to other co-morbidities.
  • Adequate rest
  • Adequate nutrition and hydration
  • Perform full blood count and CRP,
  • Be vigilant about other fever syndromes, e.g., dengue fever, leptospirosis, influenza and undertake appropriate tests, if indicated
  • No place for routine antibiotics
  • Steroids are not indicated at this stage unless if they are currently on steroids for any other co-morbid condition, e.g., oral steroids in nephrotic syndrome or having an acute exacerbation of asthma.
  • Warning signs for escalation of care: Difficulty in breathing or saturation at rest <94% in room air or decreasing trend of oxygen saturation
  6.3 Management of moderate disease Children with moderate disease can be managed in a Level II institution. However, consider transferring to a Level III institution with HDU/ICU facilities for children, early, if rapid worsening to severe disease is expected.
  • Monitor every four hours or more frequently if indicated to identify the possible progression of the disease (RR, PR, BP, Respiratory effort, SpO2, etc.)
  • Supplementary oxygen, if required, to maintain SpO2 >94%
  • Paracetamol 10-15mg/kg/dose as required for fever. Avoid NSAIDs unless indicated due to other co-morbidities.
  • Attend for nutrition, hydration, and other supportive care
  • Antibiotics are not required routinely. If a secondary bacterial infection is suspected, arrange FBC and CRP and other relevant investigations if laboratory facilities are available. However, if strongly suspected of a secondary bacterial infection based on clinical and/or laboratory evidence, antibiotics can be commenced (Pease refer National guidelines on Respiratory Infections in children)
  • A chest radiograph is indicated with worsening of respiratory symptoms
  • Steroids are indicated for the patients when they start requiring oxygen, worsening symptoms, or prolonged duration of symptoms without evidence of recovery (please refer to the management of severe disease) Dexamethasone 0.15mg/kg/day (maximum 6mg) once daily or in two divided doses or equivalent doses of other steroids such as prednisolone or methylprednisolone or hydrocortisone, continued for 5-14 days (decided depending on the severity and existing comorbidities). The intravenous route is preferable in critically ill children.

6. 4 Management of severe and critical disease
  • All patients with progressive disease should receive standard care and be managed in the COVID 19 Ward/HDU/ICU of the original health facility until escalation to a level III center with Paediatric HDU/ICU is made available
  • Start Oxygen
    • Escalate as needed to HHFNC, CPAP, NIV or invasive ventilation
  • Monitor vital signs and SpO2 closely
  • Investigations:
    • FBC, CRP, LFT, RFT, ABG, D-Dimer, Serum Lactate
    • ECG, CXR,
    • Echo, Troponin I, LDH, S. Ferritin if needed
    • May be repeated after 24-48 hours as per clinical condition
  • Intravenous steroids
  • Consider Antibiotics
  • Complications: Need to monitor for possible complications such as thrombosis, pulmonary embolism (unwell patient with sudden worsening of hypoxemia, blood pressure or tachycardia), haemophagocytic-lymphohistiocytosis (HLH), and multi-organ failure
  • Consider prone positioning
  • Restrict fluids
  • Consider LMWH with established thrombosis (e.g Enoxheparin)
  • Manage Shock, ARDS, acute kidney injury, HLH, Myocarditis as per protocol
  • Hydroxychloroquine, chloroquine, ivermectin, azithromycin, lopinavir/ritonavir, vitamin D, vitamin C, and zinc are not recommended for routine use in children due to lack of evidence.

(Please refer to the COVID 19 Management Guidelines of severe and critical disease by the Paediatric Intensive Care Chapter of the Sri Lanka College of Paediatricians)